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CA-MRSA in Athletics Sophia V. Kazakova, MD, MPH, PhD Division of Healthcare Quality Promotion National Center for Infectious Diseases Centers for Disease Control and Prevention. Texas Department of State Health Services meeting on CAMRSA Infections Austin, TX September 9, 2004. Objectives.

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texas department of state health services meeting on camrsa infections austin tx september 9 2004

CA-MRSA in AthleticsSophia V. Kazakova, MD, MPH, PhDDivision of Healthcare Quality PromotionNational Center for Infectious DiseasesCenters for Disease Control and Prevention

Texas Department of State Health Services

meeting on CAMRSA Infections

Austin, TX

September 9, 2004

objectives
Objectives
  • To present an outbreak investigation of CAMRSA skin infections among members of a professional football team
  • To summarize risk factors in football players and other sports participants
  • To present infection control and prevention measures in football outreaks
sports participation in u s
Sports Participation in U.S.
  • National Federation of State High School Associations (2003)
    • 6,903,552 (53%)
      • Football 1,032,420 (18%)
      • Basketball 1,002,797 (13%)
      • Wrestling 244, 984 (4%)
  • National Collegiate Athletic Association (2002-03)
    • 377,641
      • Football 59,640 (16%)
      • Basketball 30,669 (8%)
      • Wrestling 5,986 (2%)
  • Does not account for professional, extramural, club teams (rugby)
skin injuries a common risk for infection
Skin Injuries: A Common Risk for Infection
  • Most frequent and well recognized skin infections
    • Herpes simplex, S. aureus, Streptococcus pyogenes
    • “Scrum pox”, “herpes rugbiorum”, “scrum strep”
  • Few reports in the literature
  • Few training opportunities in infection control for athletic trainers
first reports of s aureus outbreaks in football
First Reports of S. aureus Outbreaks in Football
  • New Hampshire 19641
  • North Carolina 19772
  • Illinois 19792

1Pollard JG. The Staphylococcus plagues a football team. College Health 1966;234-238.

2 Bartlett PC, Martin RJ, Cahill BR. Furunculosis in a high school football team. Amer J Sports Med 1982;10:371-74.

first mrsa infections in sports
First MRSA Infections in Sports
  • 1994: High school wrestling team in Vermont1
    • 7 (22%) of 32 had MRSA
    • Follow-up nasal carriage survey of all wrestlers
      • 40% colonized with S. aureus
      • 0% with MRSA
  • 1996: England2
    • 5 rugby players with MRSA
    • Treated with erythromycin and clarithromycin

1 Lindenmayer JM, et al. Arch Intern Med 1998;158:895-9.

2Stacey AR, et al. Br J Sports Med. 1998:32;153-154

slide7

Contact

  • Crowding
  • Contaminated items
  • Compromised skin
  • Cleanliness
slide8

November 9, 2003:

    • State DOH and CDC were notified of a cluster of MRSA abscesses among Team X
the bigger they are the harder they fall

The Bigger They Are The Harder They Fall

CAMRSA Among Professional Football Players - 2003

objectives for investigation
Objectives for Investigation
  • Determine if skin infections were due to healthcare-associated MRSA or due to community-associated MRSA
  • Identify possible sources and risk factors for infection
  • Develop recommendations for control of the outbreak
slide12
MRSA case
    • Skin infection in team X player or staff during 2003 football season
    • MRSA on culture
  • Observational studies
    • Field investigation
    • Training facility
      • Contact
      • Towel sharing
      • Hand washing
      • Other hygiene practices
slide13
Cohort study
    • Players’ positions
    • Demographic characteristics
    • Healthcare exposures
    • Skin abrasions (turf burns)
    • Personal hygiene
    • Use of saunas, whirlpool spas, training and therapy equipment
s aureus colonization study
S. aureus Colonization Study
  • Nasal Swab Survey
    • Players
    • Staff
  • Turf Burn Swab Survey
    • Players
slide15

Environmental Study

  • Weight Training
  • Physical Therapy
  • Game Play
  • Whirlpool Spa
  • Sauna
team x players
Team X Players
  • 58 Players
  • Median Age: 26 years (22-41)
  • Race: white - 30 (52%)
  • Weight group*:

BMI > 30 31 (58.5%)

BMI 25-30 21 (39.6%)

BMI 18.5 – 24 (Normal weight) 1 (1.9%)

*NCHS classification

Body Mass Index (BMI) Formula: kg

(m)2

cases of mrsa infection in team x players 2003

2

1

0

3

10

17

24

31

7

14

21

28

5

12

19

26

2

9

16

23

30

7

August

September

October

November

Date of Onset

Cases of MRSA Infection in Team X Players, 2003

Number of

Episodes

eight mrsa cases
Eight MRSA Cases
  • All infections were:
    • at turf burn sites
    • on elbows, forearms, or knees
  • 6 required surgical incision and drainage
  • Three first case-players received Keflex
  • 2 received IV abx
cases of mrsa infection in team x players 200322

2

1

0

3

10

17

24

31

7

14

21

28

5

12

19

26

2

9

16

23

30

7

August

September

October

November

Date of Onset

Cases of MRSA Infection in Team X Players, 2003

Intervention

Number of

Episodes

slide26

Cohort Study

* Chi-Square with α = 0.05

slide27

Observational Study

  • Turf burns
    • ~3/player/week
    • Frequently not covered
    • Trainers had poor hand hygiene
  • Personal hygiene
    • Frequent towel sharing
    • Skipping showers before using spas
  • Close contact
    • Lineman and linebackers
    • Team meetings
    • Adjacent lockers
observational study
Observational Study
  • Training facility
    • Equipment not cleaned
    • No guidelines for cleaning of spas, sauna, and steam room
  • Onsite Pharmacy for distributing antimicrobials
slide29

Review of Antimicrobial Use

Prescriptions/Person/Year

*NHANES/NAMCS data for males aged 22-41 years, 2002

slide31

Laboratory Methods and Characterization of S. aureus

  • S. aureus isolates
    • 2 MRSA abscess isolates
    • 41 MSSA isolates
  • Methods
    • Antimicrobial susceptibility testing
    • Toxin testing (PVL, A-E, H, TSST)
    • Pulsed-Field Gel Electrophoresis (PFGE) and BIONUMERICS® software
    • PCR for typing resistance gene (SCCmec)
team x mrsa abscess isolates

MRSA: Abscess

MRSA: Abscess

Team X MRSA Abscess Isolates
  • Resistant
    • to methicillin and all other β-lactams
    • to erythromycin
  • Produce Panton-Valentine leukocidin
  • Indistinguishable by PFGE
  • Contain SCCmecType IVa resistance gene, commonly found in community settings
team x mrsa compared to community strains
Team X MRSA Compared to Community Strains

100%

80%

60%

Abscess

NFL Team X

NFL Team Y

Abscess

California

College Football

College Football

Pennsylvania

Fencer

Colorado

Prison

Mississippi

Texas

Jail

Prison

Georgia

Children

Tennessee

Children

Texas

Children

Missouri

Children

California

USA300

Community

USA100

Hospital strain

USA200

Hospital strain

community associated mrsa compared to hospital mrsa

100%

80%

60%

Abscess

Team X

NFL Team Y

California

College Football

College Football

Pennsylvania

Fencer

Colorado

Prison

Mississippi

Texas

Jail

Prison

Georgia

Children

Tennessee

Children

Texas

Children

Missouri

Children

California

USA300

Community

USA100

Hospital Strain

USA200

Hospital Strain

Community-Associated MRSA Compared to Hospital MRSA
team x mrsa and mssa isolates
Team X MRSA and MSSA Isolates

100%

80%

60%

MRSA: Abscess

MRSA: Abscess

MSSA: Nasal Swab

MSSA

Nasal

and

Environmental

slide36

Summary

Skin

Abscess

cluster

  • CA-MRSA
  • Stable
  • Clone
  • ß-lactam
  • resistant
  • PVL+

Community

Football Team X

  • Players
  • Turf burns
  • Close contact
  • Poor hygiene
  • Team
  • Increased antimicrobial use
  • Contaminated environment
  • Inadequate cleaning
slide37

CA-MRSA Outbreak Interventions

  • Enhanced disease surveillance among members of the cohort
    • Systematic and routine examination of skin
    • Reporting of skin abrasions and infections by players
  • Infection treatment and containment
    • Drainage and culture of abscesses
    • Targeted antimicrobial therapy
    • Improved wound care
slide38

CA-MRSA Outbreak Interventions

  • Temporary exclusion from competition/practice
    • If contamination from the wound can not be prevented
  • Improved hand and personal hygiene
    • Access to sinks and alcohol hand gels
    • Single use towels
    • Wall soap dispensers
  • Enhanced environmental cleaning
    • Multiuse training equipment
    • Whirlpool spa
slide39

CA-MRSA Outbreak Interventions

  • Decolonization
    • Regimens
      • Chlorhexidine washes (pulse or single use)
      • Intranasal mupirocin
    • Data for decolonization in outbreak prevention are limited
    • A reasonable approach includes
      • In a closely-associated cohort
      • In an individual patient with recurrent disease
slide40

СПАСИБО! (Thank You!)

Acknowledgements

  • Professional Football Team X
  • Missouri State Health Department

Larry Phelan

Doug Dodson

  • Barnes Hospital

Victoria Fraser

  • Santa Clara County Health Department

Sarah Cody

  • CDC Epi

Thomas Boo

Jeff Hageman

Dan Jernigan

Arjun Srinivasan

Michele Pearson

Jerry Tokars

Monina Klevens

Lisa Panlilio

Denise Cardo

  • CDC Lab

Sigrid McAllister

Bette Jensen

David Lonsway

Linda McDougal

Jean Patel

Mathew Arduino

George Killgore

Fred Tenover

Roberta Carey